=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811064140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY KURTISS MCCONKEY D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15703 US HIGHWAY 12 SW
-----------------------------------------------------
City | COKATO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55321-4624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-286-2500
-----------------------------------------------------
Fax | 320-286-2501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 206
-----------------------------------------------------
City | COKATO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55321-0206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-286-2500
-----------------------------------------------------
Fax | 320-286-2501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2617
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------